DDES INFO MEMO 2004-03
Acrobat version of DDES
Info Memo 2004-03
FACTS ABOUT DOMESTIC VIOLENCE IN LATER LIFE
AND ELDER SEXUAL ASSAULT
OCCURING IN RESIDENTIAL CARE FACILITIES
Compiled by Jane A. Raymond, DHS
/DDES/Bureau of Aging
and Long Term Care Resources
Madison, WI Ė May 4, 2004
FACTS SPECIFIC TO ELDER SEXUAL ABUSE
WHAT IS SEXUAL ASSAULT?
Sexual activity that occurs under the following conditions is
assaultive or abusive*:
- A person is physically forced into contact.
- A person is threatened, manipulated and/or tricked
- A person is unable to consent to sexual activity.
- An owner or employee of certain residential facilities has
sexual contact or sexual intercourse with a person receiving
services from that facility.**
*Ramsey-Klawsnik, Holly. Widening The Circle: Sexual
Assault/Abuse and People with Disabilities and the Elderly, 1998,
Chapter 3, p. 10. (Wisconsin Coalition Against Sexual Assault, Madison,
**Section 940.225(2)(g), Wis. Stats. In addition,
Section 940.225, Wis. Stats. applies to certain programs and facilities
and makes it a crime for a person in charge of or employed by the
program or facility to intentionally, recklessly, negligently abuse a
patient or resident of the program or facility regardless of whether
injury or harm occurred. It also makes it a crime for any person in
charge of or employed by the covered programs or facilities to knowingly
permit another person to intentionally, recklessly, or negligently abuse
a patient or resident of the program or facility, again regardless of
whether injury or harm occurred. "Abuse" as defined in s.
940.295, Wis. Stats., includes conduct which is not necessary for the
treatment or maintenance of order and discipline of a facility or
program and which harms, intimidates, humiliates, threatens, frightens,
or otherwise harasses the patient or resident.
A range of behavior may be involved in the sexual assault***:
- Hands-off offenses include exhibitionism; voyeuristic
activity; forcing an individual to view pornographic materials; sexual
harassment and threats.
- Hands-on offenses include kissing, touching/molesting breasts,
genitals, and buttocks; oral/genital contact; penetration of vagina or
rectum with penis, fingers or objects.
- Harmful genital practices involve unwarranted, intrusive,
and/or painful procedures in caring of genitals or rectal area. This
includes applications or insertion of creams, ointments, thermometers,
enemas, catheters, fingers, soap, washcloths, or other objects when
not medically prescribed and unnecessary for the health and well being
of the individual. The practices meet the idiosyncratic needs of the
offender, but not the health or hygiene needs of the victims.
Perpetrators may appear obsessed with the behavior, claim that the
harmful practices are required for health or hygiene reasons, and be
reluctant to stop when instructed to by health care professionals.
These practices may co-occur with hands-off and hands-on offenses as
described above. Individuals with disabilities that render them unable
to independently bathe, use the toilet, and attend to other personal
needs are vulnerable to these practices.
***Ramsey-Klawsnik, Holly. Widening The Circle: Sexual
Assault/Abuse and People with Disabilities and the Elderly, 1998,
Chapter 3, p. 10. (Wisconsin Coalition Against Sexual Assault, Madison,
WHO ARE THE VICTIMS?
Elder sexual assault victims are individuals age 60 and older, or
who are subject to the infirmities of aging.**** While the majority of
identified abuse and/or sexual assault victims are female, males with
special needs are also vulnerable. Some elder victims may be relatively
healthy, requiring brief recuperative stays in a facility, yet abused by
a family member in that setting. Others may be long term residents who
are frail or have physical impairments or cognitive limitations.
****Section 46.90 (1) (c), Wis. Stats.
WHY ARE ELDERS VULNERABLE TO SEXUAL ASSAULT?
Individuals perceived to be particularly vulnerable, or a potentially
easy target, are often chosen for victimization by sexual predators.
Older individuals may fall into this category because of the following
- Physical frailty or diminished ability to defend themselves
- Need for assistance from others (e.g., transportation, bathing,
health care, etc.)
- Predictable routines, schedules
- Living alone or in a congregate setting
- Dementia or cognitive impairments
Adults are not necessarily less susceptible to sex crimes as
they age. Sexual abuse is motivated not by sexual desire, but by a
desire to exert power and control over others and to humiliate and
belittle the victim. We may become more vulnerable to abuse as we age.
Old age and impairment decrease personal power and thereby increase the
risk of abuse. Consequently, elderly and disabled individuals are sexual
WHAT ARE INDICATORS OF SEXUAL ABUSE?
- Unexplained venereal disease or genital infections
- Vaginal or anal bleeding Ė injury to genital area
- Torn, stained, or bloody underclothing
- Difficulty sitting or walking
- Bruises or other signs of restraint
*****"Sexual Abuse of Seniors" brochure
(undated), Texas Association Against Sexual Assault, www.taasa.org
WHAT ARE SOME OTHER INDICATORS OF EXPLOITIVE SEXUAL ACTIVITY?
TIME AND LOCATION******
Exploitive sexual activity often occurs at a time or location
unlikely to be selected by two consenting adults. For example, in a case
involving a woman who was incontinent, an aide undressed her in the
bathroom and left her seated on the toilet while the aide went to get a
wash cloth and clean clothing. When the aide returned, she found a male
resident standing in front of the woman. He had dropped his pants and
was trying to force his penis in her mouth.
******"Elder Sexual Abuse Perpetrated by
Residents in Care Settings." Holly Ramsey-Klawsnik, Victimization
of the Elderly and Disabled, March/April 2004, p.94.
The offender often has significantly greater ability than the victim
does. While the victim and offender may both have a form of dementia,
the victimís cognitive capacity may be significantly more compromised
than that of the offender. For example, a perpetrator was verbal,
ambulatory, and independent in eating and toileting. In contrast, his
victim was quite passive and required assistance with all activities of
daily living. The power differential may be physical, rather than
cognitive. For example, a male resident walked into the room of a
nonambulatory female, closed the door and molested her while she sat in
her wheelchair, unable to remove herself from the situation.
NOTICEABLE AVOIDANCE OF A SPECIFIC RESIDENT********
A dynamic observed in many cases of resident sexual assault is one
man demonstrating inappropriate desire toward multiple women. He may
approach numerous women and attempt to force unwanted sexual contact.
These attempts may not be limited to residents but involve female staff
and visitors as well. For example, a male resident, described as big and
strong, became sexually aggressive toward staff and residents. This
resident continued to grope at the breasts and peri-area of any female
within reach. In addition, the resident would make sexual gestures with
his tongue. One charge nurse stated her breasts were black and blue from
this resident. When the facility tried using a male CNA, the nursing
assistant stated he had never been groped so much in his life.
CAN SOMEONE BE SEXUALLY ASSAULTED IF THEY HAVE THEIR CLOTHES ON?
YES. Sexual assault can occur when someone is fully clothed.
Examples include: manipulation of breasts while the individual is
wearing a blouse and bra and the probing of the genital area while the
individual is wearing underwear under her nightgown. A
"hands-off" example would be forcing a fully clothed
individual to witness the perpetrator masturbating, while making sexual
comments such as "you know how bad you want it."
WHAT ABOUT SITUATIONS OF "CONSENSUAL SEX" INVOLVING A
MARRIED NON-CONSENTING COUPLE?
In order to not be considered abusive, sexual contact can only occur
between consenting adults. Elements of consent********* would include:
- Individual understands sexual nature of conduct
- Individual understands that the body is private and one has the
right to not consent
- Individual understands consequences of sexual activity (e.g., risk
of sexually transmitted diseases)
- Individual understands consequences of social taboos and societal
*********Based on the Wisconsin Coalition Against
Sexual Assault (Madison, WI) analysis of the case State v. Smith, 215
Wis.2d 84 (Ct. App. 1998)
Sometimes the ability to discern the element of consent can be quite
challenging. Invariably, the following is one of the scenarios raised
when facility staff ponder the application of consent:
"Married couple lives together in a nursing home. They actually
share a room. Both have dementia and have been adjudicated incompetent.
While it is firmly believed that neither can consent to sexual activity,
they do indeed have sexual contact with each other Ė a continuation of
a happy, married life together for some many years. It appears both
individuals enjoy the contact, are seen holding hands together at
socials, and always seek each other out"
As staff of the facility, you are aware of the sexual contact. What
are you to do? Is this a criminal justice issue, a BQA enforcement issue
and/or a facility staffing issue?
Response by DHS
The individuals appear to be happy with the contact they have with
each other even though they may not be viewed as capable of giving
knowing consent. The quality of life for this couple is better because
they are still a couple. By "seeking each other out" they seem
aware of this despite their dementia. While there would be no criminal
justice or regulatory enforcement response required in the situation
described above, the facility would want to make sure that the
respective guardians are aware of the sexual activity. It is suggested
that the facility closely monitor the individuals' reactions. Document
in their respective chart observations of the coupleís behaviors. If
there's a change Ė e.g., one appears to be bothered by the contact or
there are indications of force used by one or another or
non-consent/cooperation, then facility staff should intervene. This may
include re-contacting the respective guardians and/or contacting the
regional ombudsman program or county adult protective services agency
for assistance in developing a victim safety plan and a care plan for
It is important to note the response is not based on the fact that
they are a married couple and the role of husband and wife includes
being sexually involved. Rather, it is based on the facts that the
couple appears very loving, they seek each other out, and they seem to
always be happy in each otherís presence.
An example of sexual activity involving a married couple where staff
acted inappropriately follows:
"A caregiver was discovered Ďassistingí the sexual contact
between husband and wife in a facility. Neither was aware of what was
happening nor were they capable of consenting. She placed their hands
on each other. She undressed each of them."
In this case, this was a sexual assault by the caregiver who
disguised her conduct as "assisting the couple to enjoy each
other". Subsequently, a hearing was held and the caregiverís name
was placed on the Caregiver Misconduct Registry.
Because the issue of consensual sex can become extremely complicated
when involving individuals who have diminished capacity, it is
recommended that when such a situation is identified, that advice be
sought from others on how to best proceed. Studies have shown that
decisions made by groups are more effective than those made by
individuals when no one person has the solution, but each person can
contribute to a solution. Given the complexity of these cases, and the
fact that there are often gaps in the services needed to assist victims,
a broad range of professionals looking at a case and planning possible
interventions is more likely to arrive at effective results. Therefore,
if your entity is seeking guidance on how to proceed with a case of
possible sexual assault, call your countyís lead elder abuse agency
contact and if timely, ask to be placed on the next Elder Abuse
Interdisciplinary Team (I-team) meeting for a discussion of the
situation. You may also choose to consult with staff from the Bureau of
Quality Assurance (BQA) (email@example.com
or 608-243-2019) or an ombudsman with the Board on Aging and Long Term
FACTS SPECIFIC TO DOMESTIC VIOLENCE IN LATER LIFE
WHAT IS DOMESTIC ABUSE IN LATER LIFE?**********
While all intimate relationships have conflicts, an abusive power and
control dynamic characterize abusive relationships. In an abusive
relationship, one party fears the other and attempts to comply with the
other's wishes to avoid the consequences of confrontation. Forms of
domestic violence include, but are not limited to, physical, sexual,
verbal and emotional abuse as well as financial exploitation. Often it
is a combination of one or more of these types of abuse. It is important
to understand domestic violence as a pattern of assaultive and
coercive behaviors, designed to control another person. Abusers believe
they are entitled to use any method necessary (e.g., use of threats and
intimidation) to control how the victim thinks, feels and behaves. Abuse
in later life can occur wherever the victim resides, which can include
oneís own home in the community or a residential care facility. When
the abuser is a family member, spouse or trusted caregiver, it is likely
the victim will want to maintain the relationship while ending the
**********Wisconsin Coalition Against Domestic
Violence (Madison, WI) website: http://www.wcadv.org/gethelp
(May 2004) and the National Clearinghouse on Abuse in Later Life
(Madison, WI) website: http://www.ncall.us/#Definitions
WHO ARE THE VICTIMS?
Abuse in later life happens to people of all genders. Nationally
reported cases of elder abuse indicate that about two-thirds of the
victims are women, while one-third of the victims are men. While
domestic violence programs in Wisconsin primarily serve women of all
ages, many interventions such as safety plans, protective restraining
orders and one-on-one counseling are useful and available for older
victims of all genders.
FACTS THAT APPLY TO BOTH DOMESTIC VIOLENCE IN LATER LIFE AND
SEXUAL ASSAULT OF THE ELDERLY
WHO ARE THE PERPETRATORS?
Anyone. Perpetrators may be family members, residents, or
- Family member: (may take two forms i.e., (1) family member, or
- Family members (non-spouse) can include a parent, child, or
grandchild, sibling, aunt, uncle, cousin, niece or nephew.
- Spouses or partners can be abusive or sexually assault their
mate. In some long-term relationships, the abuse may have been going
on for 40, 50, even 60 years. In other situations, the relationship
and abuse may be relatively new (generally following divorce or death
of previous spouse). Sometimes onset of abuse may occur during older
years due to medical conditions, such as Alzheimerís disease, that
MAY manifest in violent or sexually inappropriate behavior.
- Resident-to-Resident abuse occurs in facility settings where a
perpetrating resident forcibly (or in the absence of informed consent)
engages in sexual contact or intercourse with another resident. The
victim typically demonstrates decreased capacity in the areas of
physical and/or mental health compared to the perpetrator.
- Caregivers may also be abusers. A caregiver is a professional,
paraprofessional or volunteer providing services to an individual
under a contractual or formal arrangement. This definition also
includes "caregivers" as defined in Wisconsin law, section
50.065(1)(ag) 1., Wis. Stats.
- Others: Abuse may occur by persons who do not fit in the
categories above. Sometimes these individuals are friends, neighbors
or guardians of the victim. In these cases, the perpetrator is known
and often has an ongoing relationship with the victim. In other cases,
the perpetrator is a stranger. For example, a lay minister may visit
residents at a nursing home but use this time as an opportunity to
sexually prey on incompetent or frail elderly who may not be able to
report the abuse.
***********Ramsey-Klawsnik, Holly. Widening The
Circle: Sexual Assault/Abuse and People with Disabilities and the
Elderly, 1998, Chapter 3, p. 11. (Wisconsin Coalition Against Sexual
Assault, Madison, WI).
The majority of identified abusers and sexual offenders are male.
Female physical abuse and sexual offending does occur, however, and
allegations involving female perpetrators also require careful
investigation and intervention. While traditionally a perpetrator of
domestic abuse has been described as an "intimate partner"
(e.g., spouse, life partner or significant other), more recently the
list of possible abusers has been expanded (e.g., adult children,
grandchildren, nieces, nephews as well as caregivers.)************ The
expanded list of perpetrators acknowledges that older persons may have
ongoing, trusting relationships with individuals they care about or love
yet they are not physically intimate with.
************Wisconsin Coalition for Advocacy,
Wisconsin Coalition Against Domestic Violence, Wisconsin Coalition
Against Sexual Assault and IndependenceFirst. Cross Training
Workbook: Violence Against Women with Disabilities. Madison, WI.:
WHAT ARE POTENTIAL PERPETRATOR BEHAVIORS?*************
- Minimizes or denies abuse has occurred and instead blames the
victim for being clumsy or difficult
- Attempts to convince health care workers that the patient is
incompetent or grossly confused
- Senior is kept in an overmedicated state
- Overly protective or controlling of a family member (e.g., refuses
to allow the elder to be alone with visitors, declines to leave the
room during an exam, treatment or personal cares)
- Controls most of the residentís daily activities
- When visiting, either keeps door closed or frequently draws
- Wants to be present for all interviews
- Answers for the victim
- Overly attentive, acts loving and compassionate to victim in the
- Charming and friendly to health care workers or
abusive to health care workers (e.g., Iíll call your
supervisor" or "Iíll sue you.")
- Uses the system to their advantage or against the victim by
knowing "their rights"
*************This material was adapted from the
handbook, From a Web of Fear to a Community Safety Net: Cross
Training on Abuse in Later Life, published by the Pennsylvania
Coalition Against Domestic Violence in coordination with the
Pennsylvania Department on Aging: Harrisburg ,PA., 2001, p. 17.
WHAT ARE VICTIM BEHAVIORS THAT MAY INDICATE ABUSE?**************
- Remaining silent when asked questions about the
abusive/exploitative acts s/he were subjected too
- Looks to the abuser to answer questions
- Minimize and deny abuse occurs or takes the blame for the abuse
(e.g., "If I had been on time when she came to pick me up for
church services then this would not have happened.")
- Makes a statement like: "He wonít like that." or
"I donít think that will be allowed."
- Protecting the abuser Ė trying to avoid police intervention and
the arrest of the abuser
- Asks worker to leave and/or refuses offer of service(s)
- Asks for help and then changes his/her mind
- Doesnít follow through on "the plan"
- Sudden change in behavior
- Fear of being alone with caregiver(s) or family member(s)
- Talks fondly of the abuserís good qualities
**************Ibid., p. 18
WHAT ARE SOME REASONS THAT VICTIMS MAY NOT WANT TO REPORT
There are many reasons that victims may be hesitant to report
situations of abuse or exploitation. Some victims of family violence may
wish to continue their relationship with their abusive family member,
hoping that the assaults will stop and the relationship continues. Many
other elderly victims fear retaliation if they either disclose abuse or
try to leave an abusive situation. Victims who have been abused/sexually
assaulted by another resident may be embarrassed or ashamed to talk
about what has happened. They may believe they are in some way to blame
for the incident. Or they may be afraid that they will not be believed
or somehow punished if they tell staff.
***************Abuse of the Elderly in
Regulated Facilities: Report and Recommendations. Wisconsin
Coalition Against Sexual Assault and Wisconsin Coalition Against
Domestic Violence, Madison, WI: 2003, p. 20.
Many older adults have additional barriers to reporting the abuse
and/or sexual assault that was committed against them. Some of these
unique issues include:
- Generational values that instill strongly held beliefs among many
older persons that negative issues involving the family should never
be discussed. This belief constructs a barrier for many older
persons who are assaulted/abused by family members.
- Conflicting feelings toward the perpetrator, if s/he is a family
- Lack of information and/or resources about abuse and/or sexual
assault and the agencies that might provide services and support.
- Inability to communicate with someone other than the person
committing the abuse and/or sexual assault due to isolation, fear or
- Inability to communicate verbally due to illness or disability
that prevents disclosure.
- Lack of awareness by the older person that what s/he is
experiencing or has experienced is abuse and/or sexual assault.
- An attempt to disclose to someone that abuse and/or sexual assault
is occurring is met with disbelief or is discounted by the listener
because of the victim's age and/or frailty.
- Many older victims of sexual assault may be adult survivors of
childhood abuse, so abuse in later life is treated with the same
silence that they experienced as children.
WHAT ARE EFFECTS OF ABUSE AGAINST OLDER INDIVIDUALS?****************
Older adults, like anyone else, will be affected by the trauma of
abuse. Everyone experiences trauma differently. Some people will be
severely traumatized by their abuse while others may not outwardly
appear to have any long-term impact. A "hands-off offense" can
severely traumatize one person while a person who was forcibly raped may
not seem to experience long-term traumatic affects. Even if the victim
could not physically feel or appears to have no memory of the assault,
s/he may still be traumatized.
****************To Live Without Fear and
Violence: Sexual Assault and Domestic Abuse Against Older Individuals:
Participant Manual and Model Protocols for Law Enforcement Responding to
Sexual Assault and Domestic Abuse Against Older Individuals. Wisconsin
Coalition Against Sexual Assault, Inc., Madison, WI., 2004, pages 41 and
Abuse can cause harmful psychological, physical, and behavioral
effects. If the abuse is left unaddressed, these affects can potentially
be very long lasting and persistent for the individual. It is estimated
that 3.5 million women 60 years of age and older are survivors of
childhood sexual abuse (Farris and Gibson 1992). Below is a listing of
both short-term and long-term effects that may indicate the presence of
Short-Term Effects Long-Term Effects
-Anxiety -Persistent anxiety and fear
-Fear -Feelings of shame or guilt
-Anger -Low self-esteem
-Withdrawal -Emotional numbness
-Sexualized behavior -Relationship and sexual problem
-Nightmares or trouble sleeping -Sleep disturbances
-Acting out -Recurring flashbacks, nightmares, or intrusive
-Chronic stress and other health problems
-Drug and alcohol abuse
-Dissociative identity disorder
Older adults have usually developed a vast array of coping skills
over their lifetimes. Service providers can assist a victim to recognize
these coping skills, how they were applied in the past, and how they can
be utilized to address the current situation. It should not be assumed
that elderly victims of sexual assault displaying no psychological
trauma are unharmed. Many factors determine whether or not internal
distress will be openly displayed, including personality, history,
cultural and religious background, psychosocial functioning, and
*****************"Elder Sexual Abuse Perpetrated
by Residents in Care Settings." Holly Ramsey-Klawsnik, Victimization
of the Elderly and Disabled, March/April 2004, p.93.
WHAT TYPES OF QUESTIONS SHOULD I ASK ABOUT ABUSE, NEGLECT &
Asking questions about domestic violence and sexual assault in later
life must always be done with great care and sensitivity. While it is
recommended that entities screen all individuals who they serve
concerning family violence within their first week of participation or
residency, screening questions should continue to be asked periodically.
It is believed that once rapport has been established questions may be
asked in a more conversational manner.
Examples of indirect ways of asking about abuse, neglect and
- Tell me about who you normally see, volunteer or visit with during
- Who do you especially look forward to seeing, visiting and/or
- Anyone you donít enjoy as much?
- What would you do if someone made you mad? If they wanted you to
do something you didnít want to do?
- Do you think you are more assertive at your current age, or were
you more assertive when you were younger?
- If you and your (spouse, son, daughter, nurseís aide, physician,
etc.) have a disagreement, who usually wins? How do they (you) win?
With more direct questions, prefacing them with a very direct
statement would be best. For example, you may wish to start out as
follows: "Iím going to ask you some questions about conduct that
may be physical, financial or sexual abuse. These can be issues that
people have in their lives, but in the past were not asked about. Iím
asking about them now, because sometimes people are currently
experiencing them, or abuse from the past is affecting how they feel
Examples of direct questions****************** follow.
- Has any family member, resident or staff member ever physically
harmed you? Have you been struck, slapped or kicked? Has your hair
- Have you been tied down or locked in a room?
- Have you been threatened with punishment or deprived of things
because you did not comply?
- Have you received the "silent treatment?" Have you been
- Has anyone touched you in a sexual way without your permission?
- Is money being stole from you or used inappropriately?
- Have you been forced to sign any legal documents (e.g., power of
attorney for finances, will) against your wishes?
- Have you been forced to make purchases against your wishes?
Adapted from: Elder Abuse. Laurel H. Krouse,
MD, Paoli Memorial Hospital, Paoli, PA., eMedicine.com,inc. [Web
June 5, 2001.
Follow-up questions (if abuse is identified):
- How long has the situation been occurring?
- Is it an isolated incident?
- When do you think the next episode may occur?
- Is the person who hurt/harmed you still present in the facility?
- What would you like to see happen?
- Have you ever received help for this problem before?
WHAT SHOULD I SAY IF A RESIDENT DISCLOSES ABUSE OR NEGLECT?
Convey to the patient that she/he does not deserve to be hurt or
controlled (if abused) or that she/he has a right to be cared for with
dignity and respect (if neglected).
WHO SHOULD I CALL WHEN I GET STUCK?
Entities should notify local law enforcement authorities in any
situation where there is a potential criminal violation of the law. Call
the police without delay if someone is in immediate, life-threatening
If the danger is not immediate, but you suspect that abuse has
occurred or is occurring, please relay your concerns to the Bureau of
Quality Assurance (BQA), the long-term care ombudsman program and/or law
enforcement, as appropriate. You may also elect to connect with your
countyís lead elder abuse agency contact person and if timely, ask to
be placed on the next elder abuse interdisciplinary team (I-team)
meeting for discussion of the situation. Otherwise, ask the I-team
coordinatorís opinion on how to best proceed in gaining additional
insight (some agencies have a core group that can be pulled together for
emergent cases, others have an electronic message board for seeking
The sexual assault or domestic violence program in your area can
provide insight and possible advice as well. Calls to elder abuse,
sexual assault and domestic violence agencies can occur in an anonymous
fashion, i.e., there is not a need to provide identifying information
specific to your organization or the resident you are concerned about.
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